VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY

DAILY ENDORSEMENT

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

General Data
● S. M.

● 55 years old

● Male

● Married

● Filipino

● Roman Catholic

● DOB: 06/02/1968

● From Borongan, Eastern Samar

t

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Chief Complaint

• RUQ Pain
t

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

HPI

• 1 Month PTA, Patient started experiencing a sudden, sharp, localized and constant RUQ
Abdominal pain that sometimes radiates to the back, at that time, after coming back from a party
PS(9/10).
• He feels relief whenever he uses, “omega pain killer” with PS(5/10) after use.
• 10 days later he noticed his eyes and skin became jaundiced, and he had loss of appetite which
led him to seek consult with a doctor.
• He was advised to go for an ultrasound and after the results were out he was told he had Gall
stones and a fatty liver and was prescribed, Tramadol, Buscopan, Ursodeoxycholic acid and an
unrecalled drug. Then asked to go for a repeat ultrasound.
• He stopped taking the ursodeoxycholic acid, after two days and decided he wanted to have the
stones surgically removed.
• He was then told he had “choledocholithiasis with cholecystitis” and was advised to seek consult
here at our institution.
t

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Past Medical History

• Patient is non hypertensive, non diabetic

• Patient has unrecalled immunizations; but recalls taking 2 doses of Covid Vaccines with no

booster.

• Patient claims to have food allergies to shrimp, crabs and Drug allergy to Ponstan.
t

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Family History

Maternal side: (-) Cancer, (-) Hypertension, (-) Diabetes, (-) Asthma

Paternal side: (-) Cancer, (-) Hypertension, (-) Diabetes, (-) Asthma
t

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Personal and Social History

● Patient is a Freelancer.

● Patient lives in an urban environment

● Has a good clean source of water

● has good sanitary environment

● Smoker(19.55 pack years) , occasional alcohol drinker, no illicit drug- use history

● Generally active and friendly, easy to get along with

● Usual diet: meat, fish, rice, vegetables

t

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Review of Systems

General HEENT
• Usual weight: 95kg (-) headache
(-) eye pain
• Current weight 85k (-) ear pain and discharge
(-) nasal stuffiness
• (-) weakness (-) fatigue (-) fever
(-) sore throat

Skin
Respiratory
(-) rashe
(-) cough
(-) lump (-) shortness of breath

(-) itchiness
s

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Review of Systems

Cardiovascular Musculoskeletal
(-) chest pain (-) joint pain
(-) palpitations (-) muscle weakness
(-) high blood pressure

Gastrointestinal Endocrine
(-) nausea (-) heat or cold intolerance
(-) vomiting (-) excessive sweating
(-) change in eating Habits (-) excessive thirst or hunger
(-) dysphagia (-) polyuria
(+) loss of appetite
t

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Review of Systems

Genitourinary Hematologic
(-) urinary frequency (-) fainting
(-) dysuria (-) easy fatigability

Psychiatric Nuerologic
• oriented to reality (time, place, and (-) headache
person (- ) vertig
• responds well to conversation (-) dizziness
)

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Physical Exam

General

Awake, responsive, coherent, ambulatory, not in respiratory distress with vital signs and anthropometrics as follows:

BP 100/70 mmhg
HR 78 bpm
Weight- 95 kg
RR 21 cpm
T 36.4 C
O2Sat 97 %
t

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Physical Exam

Skin Neck
(+) Jaundice, warm to touch (-) neck lesions
intact without lesions, good skin turgor (-) lymphadenopathies

HEENT Chest and Lungs

• H- No deformities, hair is well – distributed • Equal chest expansion
• E- Icteric sclerae with no eye discharges, full EOM
• E- auricles are intact, no lesions, and abnormal • No masses or lesions seen
discharges, no otalgia • Resonance noted on percussio
• N- no alar flaring, both nares intact with lesions an
abnormal discharges • Clear breath sounds in all lung fields
• T- throat pink and not inflamed
t

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Physical Exam

Cardiovascular GUT Extremeties

No swelling, No edema, extremities well-
Grossly male, no discharges,
A-dynamic pericardium perfused; CRT < 2 sec
no lesions, (-) Kidney punch
Distinct Heart sounds
sign and flank or
Normal rate and Rhythm
costovertebral tenderness

Abdomen Rectum CNS

(-) rectal bleeding and Good mental status
Round, (-) lesions (+) Abdominal discharges GCS 15 E4V5M6
Distention , normoactive bowel (-) protrusion Intact CN functions
sounds, tympanitic on
percussion, (-) tenderness on
palpation
t

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Initial Impression

Choledocholithiasis with Cholecystitis

t

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Differential Diagnosis

RULE IN RULE OUT

Hepatitis - Localized RUQ pain - HBsAg Negative

- Jaundice

Cholangitis - Localized RUQ pain (-) pyrexia

- Jaundice (-) Malaise
(-) Nausea & Vomiting

Nephrolithiasis - Localized RUQ pain radiating to the - (-) Anuria

Back - (-) Nausea
- (-) Vomiting
- (-) Lithiasis noted on sonographic
report
t

 VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsemen

Plan

For Intraoperative Cholangiogram Open cholecystectomy

t

VICENTE SOTTO MEMORIAL MEDICAL CENTE

DEPARTMENT OF GENERAL SURGERY
Daily Endorsement

THANK YOU
R